Mortality

Thermographic visualization of facial vasoconstriction is associated with 30-day all-cause mortality in medical patients; prospective observational two-site cohort study

Original Articles, Volume 20, Issue 2, Pages 89-156 (2021)

Introduction: Quick and reliable assessment of acute patients is required for accurate triage. The temperature gradient between core and peripheral temperature could possibly instantly provide information on circulatory status.

Methods: Adult medical patients, who did not receive supplementary oxygen, attending two emergency departments, had a thermographic image taken on arrival. The association between 30-day mortality and gradients was tested using logistic regression.

Results: 726 patients were studied, median age was 64 years and 14 (1.9%) died within 30 days. There was a significant association between mortality and temperature gradient, comparable to vital signs, age, and clinical intuition.

Conclusion: Temperature gradient between nose and eye had an acceptable discriminatory power for 30-day all-cause mortality.

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Thermographic visualization of facial vasoconstriction is associated with 30-day all-cause mortality in medical patients; prospective observational two-site cohort study Read More

The changing characteristics of COVID-19 presentations. A regional comparison of SARS-CoV-2 hospitalised patients during the first and second wave

Original Articles, Volume 20, Issue 2, Pages 89-156 (2021)

Background: This study assesses COVID-19 hospitalised patient demography and outcomes during wave 1 and wave 2, prior to new variants of the virus.

Methods: All patients with a positive SARS-CoV-2 swab between 10th March 2020 and 5th July 2020 (wave 1) and 1st September 2020 and 16th November 2020 (wave 2) admitted to University Hospitals Birmingham NHS Foundation Trust were included (n=4856), followed for 28 days.

Results: Wave 2 patients were younger, more ethnically diverse, had less co-morbidities and disease presentation was milder on presentation. After matching for these factors, mortality was reduced, but without differences in intensive care admissions.

Conclusion: Prior to new SARS-CoV-2 variants, outcomes for hospitalised patients with COVID-19 were improving but with similar intensive care needs.

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The evidence for assessing frailty and sarcopenia in an acute medical unit: a systematic review

Clinical Reviews, Volume 20, Issue 1, Pages 1-88 (2021)

Background/objectives: A systematic review was conducted to assess if frailty and sarcopenia were associated with poorer outcomes in older adults admitted to an acute medical unit (AMU).

Methods: Eligible studies included older adults with an unplanned admission to an AMU and included a measure of frailty or sarcopenia, completed within 72 hours of admission. Risk of bias was assessed.

Results: Of 1659 identified articles, 16 were included (4 on sarcopenia and 12 on frailty). There was significant study heterogeneity. Overall, frailty and sarcopenia were associated with worse outcomes. Targeted interventions appeared to improve outcomes.

Conclusion: Current evidence suggests some benefit in screening older adults admitted to an AMU for frailty and sarcopenia. However, further studies are required before clinical adoption.

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Diagnoses and mortality in a population without acute myocardial infarction, but with elevated highsensitive troponin I – a retrospective register-based single center study

Original Articles, Volume 20, Issue 1, Pages 1-88 (2021)

Aim: To explore, which differential diagnoses to consider in individuals with elevated troponins without acute myocardial infarction (AMI), and the mortality for those individuals.

Methods: Retrospective, register-based study on a representative sample of the Danish population with the following inclusion criteria: High-sensitive troponin I (hs-TnI) ≥25 ng/L, age ≥18 years, and exclusion of AMI.

Results: 3067 individuals without AMI but increased hs-TnI were included. Most frequent discharge diagnoses: Pneumonia (12.8%), Aortic valve disorder (11.3%), Medical observation (10.9%) and Heart failure (8.9%). The 30-days and one-year mortality was 15.8% and 32.0%, respectively.

Conclusions: A selected number of alternative diagnoses must be considered in individuals with increased hs-TnI. Due to high mortality it is crucial to carefully evaluate these individuals despite the absence of AMI.

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Acute, non-COVID related medical admissions during the first wave of COVID-19: A retrospective comparison of changing patterns of disease

Original Articles, Volume 19, Issue 4, Pages 173 – 252 (2020)

COVID-19 may have altered the case-mix of non-COVID acute medical admissions. Retrospective analysis of acute medical admissions to University Hospitals Birmingham NHS Foundation Trust, showed that medical admissions decreased in April 2020 compared to April 2019. The proportion of young adults, non-cardiac chest pain, musculoskeletal conditions and self-discharges decreased. The proportion of admissions due to alcohol misuse, psychiatric conditions, overdoses and falls increased. There were a higher number of patients admitted to ICU and greater inpatient mortality but not once COVID diagnoses were excluded. There was a significant change in hospitalised case-mix with conditions potentially reflecting social isolation increasing and diagnoses which rarely require hospital treatment, reducing. This analysis will help inform service planning.

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A change from high-flow to titrated oxygen therapy in the prehospital setting is associated with lower mortality in COPD patients with acute exacerbations: an observational cohort study

Original Articles, Volume 19, Issue 2, Pages 61 – 112 (2020)

Background: The aim of this study was to investigate 30-day mortality for COPD patients treated by ambulances in the period before and after implementation of a pre-hospital oxygen protocol.

Methods: Prehospital High-flow oxygen was used from April to September 2012 and titrated oxygen from April to September 2013. Primary outcome was 30-day mortality.

Results: 707 patients were included; 209 in the high-flow group and 498 in the titration group. Of these, 56 and 132 arrived with acute exacerbation (AE). Overall 30-day mortality was 11.5% vs. 9.4% (p=0.41), respectively. For patients with AE, it was 19.6% vs. 4.6% (p=0.001).

Conclusion: Change of treatment protocol is associated with a lower 30-day mortality for patients registered with acute exacerbation, but not for all COPD patients.

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A change from high-flow to titrated oxygen therapy in the prehospital setting is associated with lower mortality in COPD patients with acute exacerbations: an observational cohort study Read More

Higher In-Hospital Mortality in Patients with Nonspecific Complaints Presenting to the Emergency Department

Original Articles, Volume 18, Issue 4, Pages 205 – 264 (2019)

Background: Nonspecific complaints (NSC) at the Emergency Department (ED) are not well researched yet.

Objective: To investigate the number of patients who could be classified as having NSC early after arrival in the ED using an algorithm.

Method: Retrospective cohort study was conducted among all hemodynamically stable non-trauma adult patients with MTS category orange/yellow visiting the ED. Patients who had no specific complaints/signs, predefined on a list, were categorized as NSC.

Results: In total, 2419 patients, of whom 102 (4.2%) presented with NSC. Hospitalization was more prevalent (85.3% vs. 69.0%, p<0.001) and in-hospital mortality was higher in the NSC-group (11.8% vs. 3.5%, adjusted OR 2.0, 95% CI 1.0-3.9, p=0.04). Conclusion: Using an algorithm it is possible to identify NSC patients who have (worse) outcomes than those classified as SC.

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Prediction models for mortality in adult patients visiting the Emergency Department: a systematic review

Clinical Reviews, Volume 18, Issue 3, Pages 137 – 204 (2019)

We provide a systematic overview of literature on prediction models for mortality in the Emergency Department (ED). We searched various databases for observational studies in the ED or similar setting describing prediction models for short-term mortality (up to 30 days or in-hospital mortality) in a non-trauma population. We used the CHARMS-checklist for quality assessment. We found a total of 14.768 articles and included 17 articles, describing 22 models. Model performance ranged from AUC 0.63- 0.93. Most articles had a moderate risk of bias in one or more domains. The full model and PARIS model performed best, but are not yet ready for implementation. There is a need for validation studies to compare multiple prediction models and to evaluate their accuracy.

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The way healthcare is funded is wrong: it should be linked to deaths as well as age, gender and social deprivation

Original Articles, Volume 17, Issue 4, Pages 173 – 240 (2018)

Background: most spending on health occurs in the last few months of life. This study explored the number of deaths in England and their relationship to healthcare funding.

Methods: post hoc analysis

Results: the number of deaths range from 3.3 to 15.1/1000/year, and the number of deaths per general practitioner from 5.2 to 27.3/year. Hospital deaths range from 12 to 52/1000 admissions. The correlation between the allocation index used for funding and deaths is not perfect and suggests that some regions may get up to17% less and others 14% more funding than is equitable.

Conclusion: there is considerable variation in the prevalence of death throughout England. If healthcare funding considered the local number of deaths it would be more equitable.

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Exploring the value of routinely measured hematology parameters for identification of elderly patients at high risk of death at the Emergency Department

Original Articles, Volume 17, Issue 4, Pages 173 – 240 (2018)

Of the warning scores in use for recognition of high-risk patients at the Emergency Department (ED), few incorporate laboratory results. Although hematological characteristics have shown prognostic value in small studies, large studies in elderly ED populations are lacking. We studied the association between blood cell and platelet counts and characteristics as well as C-reactive protein (CRP) at ED presentation with mortality in non-multitrauma patients ≥ 65 years. Comparison between survivors and non-survivors showed small, significant differences with AUROCs ranging between 56.6% and 65.2% for 30-day mortality. Combining parameters yielded an evident improvement (AUROC of 70.4%). Efforts should be pursued to study the added value of hematological parameters on top of clinical data when assessing patient risk.

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